Tufts Medicine Care at Home

“Based on records reviewed and interviews, for one of three sampled patients (Patient #1), who upon admission it was made known to the Hospice that his/her wishes for Advanced Directives included that he/she had elected a code status of DNR/DNI (Do not Resuscitate/Do not Intubate), the Hospice failed to ensure that his/her advance directive documentation, including a Medical Orders for Life-Sustaining Treatment (MOLST) form, was obtained, maintained, and included in his/her clinical record/home chart and readily accessible for family members and/or emergency personnel. Findings include:Review of the Hospice’s Advance Directives for Health Care Policy, dated 09/2025, indicated that the existence and location of any advance directives will be documented in the patient’s medical record and that a copy of any advance directive will be requested for inclusion in the medical record.Patient #1 was admitted to hospice services in February 2026 with diagnoses that included malignant melanoma, metastasis to the brain, lung nodules, altered mental status, diabetes mellitus without complication, and bilateral leg weakness.Review of Patient #1’s medical record indicated the hospital record identified Patient #1’s code status as DNR/DNI.Review of the Hospice Initial Assessment, dated as completed 02/11/26, by Nurse #1 also documented Patient #1’s code status as DNR/DNI.Review of Patient #1’s Hospice Clinical Record and Home Chart, indicated it did not include a MOLST form or have any other supporting documentation related to Patient #1’s advance directives status as DNR/DNI. status.During a telephone interview on 06/03/26 at 9:45 A.M., Family Member (FM) #1 said Patient #1 was admitted to hospice with advance directive status as DNR/DNI and that hospice staff were aware of Patient #1’s wishes. FM #1 said Nurse #1 informed the family that a MOLST form had been completed and that a copy would be provided to them for his/her home record, but said the family never received a copy. FM #1 said that when the family notified hospice staff of Patient #1’s death on 04/25/26, hospice staff requested a copy of the MOLST form, but no copy was available in the home.During a telephone interview on 06/15/26 at 2:51 P.M., Nurse #1 said that during the initial admission assessment to the Hospice program, Patient #1 and FM #1 confirmed that Patient #1 wished to be DNR/DNI. Nurse #1 said she believed a copy of the MOLST form had been placed in the medical record and assumed FM #1 already had a copy. Nurse #1 said she did not verify that a copy of the MOLST form was present in the Patient #1’s hospice clinical record or home chart. Nurse #1 said she did not ensure that advance directive documentation reflecting Patient #1’s DNR/DNI status was obtained and maintained in his/her records.During a telephone interview on 06/15/26 at 2:14 P.M., Nurse #2 said that when FM #1 reported Patient #1’s death, she searched his/her Hospice record and was unable to locate a MOLST form or documentation confirming Patient #1’s DNR/DNI status. Nurse #2 said she could not complete an RN pronouncement of his/her death without documentation verifying Patient #1’s code status, so she instructed the family to call 911.During a telephone interview on 06/15/26 at 10:02 A.M., the former Director of Clinical Operations (DCO) said that Patient #1’s hospital record was maintained in an external electronic medical record system that hospice nursing staff could not access. The DCO said that when FM #1 reported Patient #1’s death, Nurse #2 was unable to locate documentation confirming Patient #1’s DNR/DNI status. The DCO said that later that same day, the Hospice Medical Director accessed Patient #1’s hospital record and confirmed that Patient #1 had a MOLST form and was designated as a DNR/DNI.The DCO said Nurse #1 assumed the MOLST form had been uploaded to Patient #1’s hospice record and did not verify that the document was present in the hospice clinical record or home chart. The DCO said the absence of the MOLST form and DNR/DNI documentation contributed to hospice staff’s inability to verify Patient #1’s code status when notified of the patient’s death. The DCO said the Agency failed to ensure that Patient #1’s advance directive documentation was included in and available through the clinical record and that a copy was available at his/her home.”

“This Standard is not met as evidenced by:Based on observation and staff interview, the facility failed to maintain egress doors in accordance with NFPA 101 section 19.2.2. NFPA 101 section 19.2.2.1 Components Permitted states components of means of egress shall be limited to the types described in 19.2.2.2 through 19.2.2.10.NFPA 101 section 19.2.2.2.1 states doors complying with 7.2.1 shall be permitted.NFPA 101 section 19.2.2.2.2 states locks shall not be permitted on patient sleeping room doors, unless otherwise permitted by one of the following:(1) Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted, provided that such devices do not restrict egress from the room.(2) Locks complying with 19.2.2.2.5 shall be permitted.NFPA 101 section 19.2.2.2.4 states doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:(1) Locks complying with 19.2.2.2.5 shall be permitted.(2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.(3)*Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.(4) Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.(5) Approved existing door-locking installations shall be permitted.NFPA 101 section 7.2.1.6.1.1 states approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(1) The door leaves shall unlock in the direction of egress upon actuation of one of the following:(a) Approved, supervised automatic sprinkler system in accordance with Section 9.7(b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6(c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6(2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a) The force shall not be required to exceed 15 lbf (67 N).(b) The force shall not be required to be continuously applied for more than 3 seconds.(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1⁄8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTILALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, the following items were observed regarding means of egress:Emergency egress door 192B left side did not sound the alarm as required. The right side worked properly and both doors opened after 15 seconds.This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency egress. As a result, the facility failed to comply with NFPA 101 section 19.2.2.2.4 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observations and confirmed by staff, the facility failed to ensure that the emergency lighting is in accordance with NFPA 101 section 19.2.9.1 and 7.9. NFPA 101 19.2.9.1 states emergency lighting shall be provided in accordance with Section 7.9. NFPA 101 7.9 states emergency illumination shall be provided for a minimumof 1 1⁄2 hours in the event of failure of normal lighting. 7.9.2.6* Existing battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code. 7.9.3 Periodic Testing of Emergency Lighting Equipment.7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwisepermitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1 1⁄2 hours if the emergency lighting system is battery powered.(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.(4) A visual inspection shall be performed at intervals not exceeding 30 days.(5) Functional testing shall be conducted annually for a minimum of 1 1⁄2 hours.(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 1 1⁄2-hour test.(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11⁄2 hours.(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, the following items were observed regarding emergency lighting:Multiple emergency lighting battery packs did not function with the push of the test button during walk through facility, representing all of the battery packs that were checked.This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency egress. As a result, the facility failed to comply with NFPA 101 section 19.2.9.1 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observations and confirmed by staff, the facility failed to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 “Life Safety Code.” Chapter 19 “Existing Health Care Occupancies,” section 19.3.2.5.1 states cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.NFPA 101 section 9.1.1 Gas states equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.NFPA 101 section 9.2.3 Commercial Cooking Equipment states that commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.NFPA 101 section 19.3.2.5.3 states within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following conditions are met:(9) A switch meeting all of the following is provided:(a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.(b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.(c) The switch is on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cooktop or range, independent of staff action.NFPA 96 section 11.2.1* states maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.NFPA 96 section 10.2.6 states Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer’s instructions, and the following standards where applicable:(1) NFPA 12(2) NFPA 13(3) NFPA 17(4) NFPA 17ANFPA 17 section 11.2.1 states on a monthly basis, inspection shall be conducted in accordance with the manufacturer’s listed installation and maintenance manual or owner’s manual.NFPA 17 section 11.2.1.1states as a minimum, this “quick check” or inspection shall include verification of the following:(1) The extinguishing system is in its proper location.(2) The manual actuators are unobstructed.(3) The tamper indicators and seals are intact.(4) The maintenance tag or certificate is in place.(5) The system shows no physical damage or condition that might prevent operation.(6) The pressure gauge(s), if provided, is inspected physically or electrically to ensure it is in the operable range.(7) The nozzle blowoff caps, where provided, are intact and undamaged.(8) Neither the protected equipment nor the hazard has been replaced, modified, or relocatedFindings include: During the morning and afternoon hours of 11/06/25 while touring the facility, the following items were observed regarding cooking facilities:o No monthly checks of ansul system.o Documentation indicated facility has performed annual maintenance on ansul system instead of required semi-annual maintenance. Dates of vendor service were 01/08/25, 07/08/24, and 08/04/23.o Documentation indicated facility has performed annual maintenance on hood instead of required semi-annual maintenance. Dates of vendor service from Cochrane Ventilation were 05/13/25, 07/08/24 (invoice only, no report), and 08/04/23 (invoice only, no report).This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 101 section 19.3.2.5.1 through 19.3.2.5.5 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with LSC Section 19.3.4.1, Section 4.6.12, Section 9.6, and NFPA 72, 2010 Edition.NFPA 101 section 19.3.4.1 states health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.NFPA 101 section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.NFPA 101 section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, Table 14.4.5 (6) requires systems with sealed batteries to have the battery charger tested annually, replace the battery every 5 years, to conduct a 30-minute battery discharge test annually, and to conduct a load voltage test semi-annually.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, and based upon a report from Davco Systems dated 09/11/25, the following items were observed regarding fire alarm testing and maintenance:• Previous maintenance done on 09/16/24• No documentation of semi-annual off-premises transmission of alarm or load voltage testing• No documentation of annual 30-minute battery discharge testThis deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 101 section 9.6.1.3 and 9.6.1.5 and NFPA 72 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system. NFPPA 101 section 19.3.5.1 states buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.NFPA 101 section 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.NFPA 101 section 19.3.5.4 states the sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).NFPA 101 section 19.3.5.5 states in Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as non-sprinklered.NFPA 101 section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:(1) NFPA 13, Standard for the Installation of Sprinkler Systems(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in HeightNFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, and based upon a report from davco Systems dated 09/11/25, the following items were observed regarding sprinkler system maintenance and testing:• Previous maintenance 09/16/24. Tags on system had March 2025 in between. • No quarterly testing during survey period. Missing Q2 2025 and Q4 2024. Tags on system indicated as such.• No monthly psi readings taken during survey period.• No documentation of 5-yr internal.This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 101 section 9.7.5 and NFPA 25 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observation and staff interview, the facility failed to maintain the fire extinguishers in accordance with NFPA 101 section 19.3.5.12.NFPA 101 section 19.3.5.12 states portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.NFPA 101 section 9.7.4.1* states where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.NFPA 10 section 8.3.1 General states at intervals not exceeding those specified in Table 8.3.1, fire extinguishers shall be hydrostatically retested.NFPA 10 table 8.3.1 states Hydrostatic Test Intervals for Extinguishers are as follows:1) Stored-pressure water, water mist, loaded stream, and/or antifreeze (5 years)2) Wetting agent (5 years)3) AFFF (aqueous film-forming foam) (5 years)4) FFFP (film-forming fluoroprotein foam) (5 years)5) Dry chemical with stainless steel shells (5 years)6) Carbon dioxide (5 years)7) Wet chemical (5 years)8) Dry chemical, stored-pressure, with mild steel shells, brazed brass shells, or aluminum shells (12 years)9) Dry chemical, cartridge- or cylinder-operated, with mild steel shell (12 years)10) Halogenated agents (12 years)11) Dry powder, stored-pressure, cartridge or cylinder-operated, with mild steel shells (12 years)Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, and based on the facility’s documentation, the following items were observed regarding portable fire extinguishers:• No documentation of monthly extinguisher checks.• No documentation of annual service.This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 101 section 19.3.5.12 and NFPA 10 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observations and confirmed by staff, the facility failed to ensure that all fire doors are maintained as required. NFPA 101 section 19.7.6 Maintenance and Testing states see 4.6.12.NFPA 101 section 4.6.12.1 states Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.NFPA 101 section 4.6.12.2 states no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction.NFPA 101 section 4.6.12.3* states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.NFPA 101 section 4.6.12.4 states Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.NFPA 101 section 4.6.12.5 states maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.NFPA 101 section 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.NFPA 80 section 5.2.1* states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, and based upon the facility’s documentation, the following items were observed regarding maintenance, inspection, and testing of doors:• No documentation of annual fire door testing. This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 101 section 19.7.6 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This Standard is not met as evidenced by:Based on observations and confirmed by staff, the facility failed to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 99, Health Care Facilities Code.NFPA 99 section 6.3.4.1.1 states where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.NFPA 99 section 6.3.4.1.2 states additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.NFPA 99 section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, the following items were observed regarding maintenance and testing of electrical systems:• No documentation of annual receptacle testing.This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 99 chapter 6 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“This standard is not met as evidenced by:Based on observation and staff interview, the facility failed to maintain the automatic emergency generator system in accordance with LSC Section 19.5.1, NFPA 99 and NFPA 110. NFPA 101 section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.NFPA 101 section 9.1.3 states Emergency Generators and Standby Power Systems, where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2. NFPA 101 section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.NFPA 110 section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.NFPA 110 section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.NFPA 110 section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.NFPA 110 section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established.NFPA 110 section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. NFPA 110 section 8.3.4.1 states the permanent record shall include the following:(1) The date of the maintenance report.(2) Identification of the servicing personnel.(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced.(4) Testing of any repair for the time as recommended by the manufacturer.NFPA 110 section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Findings include: During the morning and afternoon hours of 11/06/25 while touring the facility, and based upon the facility’s documentation, the following items were observed regarding generator maintenance and testing:• No documentation of any generator maintenance other than a minor on 03/05/25. • No documentation of 2-hr load test or monthly generator running under load to at least 30% of rated capacity.• No documentation of monthly generator checks.• No documentation of weekly generator checks.• No documentation of transfer switch maintenance. • No documentation of a fuel sample test taken during the survey period or evidence of any previous fuel sample tests. This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency. As a result, the facility failed to comply with NFPA 99 chapter 6 and NFPA 110 and the above referenced sections. The finding was reviewed with and acknowledged by the facility’s Administrator during the exit conference.”

“Based on clinical record review and staff interview, the Hospice interdisciplinary group failed to complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 1 patient (#11) out of a total sample of 27 patients reviewed.Findings include: Review of the agency policy, titled Initial and Comprehensive Assessments, revised 6/2025, indicated the following:*The comprehensive assessment incorporates the initial nursing assessment, the psychosocial, spiritual, and bereavement assessments.*The comprehensive assessment is completed within 5 days of the start of care. The comprehensive assessment is updated throughout the patient’s hospice stay, no less frequently than every 14 days.Patient #11 was admitted to Hospice on 9/6/25 with a diagnosis of Parkinson’s Disease.Review of the physician orders, dated 9/8/25-9/12/25, indicated the following:Chaplain- one time every 5 days times 5 days.Review of the interdisciplinary group (IDG) meeting notes and plan of care indicated the patient was reviewed on 9/10/25, 9/24/25, and 10/8/25.Review of the 9/10/25 IDG meeting notes and plan of care indicated the patient required an initial Chaplin evaluation and a documented spiritual plan of careReview of the 9/24/25 IDG meeting notes and plan of care indicated the patient still required an initial Chaplain evaluation and documented spiritual plan of care.Review of the 10/8/25 IDG meeting notes and plan of care indicated the Chaplain had reached out to the patient’s daughter for the initial evaluation on 10/3/25 (27 days after the start of care) and the family declined services at that time.Without the information from the Chaplain, the comprehensive assessment was not completed within 5 days of the start of care. Additionally, this information was not available to ensure the development of the plan of care.During an interview on 10/30/25 at 3:30 P.M. the Vice President of Quality, Compliance, and Risk said the Bereavement Coordinator could not find any documentation that the Chaplain completed an assessment before 10/3/25. She said there should have been an initial assessment completed within the first 5 days.”